Abnormality of cardiac structure and/or function resulting in clinical symptoms (e.g., dyspnea, fatigue) and signs (e.g., edema, pulmonary crackles), hospitalizations, poor quality of life, and shortened survival. It is important to identify the underlying nature of the cardiac disease and the factors that precipitate acute HF.
UNDERLYING CARDIAC DISEASE
Includes (1) states that depress systolic ventricular function with reduced ejection fraction (HFrEF; e.g., coronary artery disease [CAD], dilated cardiomyopathies, valvular disease, congenital heart disease); and (2) states of HF with preserved ejection fraction (HFpEF; e.g., restrictive cardiomyopathies, hypertrophic cardiomyopathy, fibrosis, endomyocardial disorders), also termed diastolic failure.
ACUTE PRECIPITATING FACTORS
Include (1) excessive Na+ intake, (2) noncompliance with HF medications, (3) acute MI (may be silent), (4) exacerbation of hypertension, (5) acute arrhythmias, (6) infection and/or fever, (7) pulmonary embolism, (8) anemia, (9) thyrotoxicosis, (10) pregnancy, (11) acute myocarditis or infective endocarditis, and (12) certain drugs (e.g., nonsteroidal anti-inflammatory agents).
Due to inadequate perfusion of peripheral tissues (fatigue) and elevated intracardiac filling pressures (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema).
Jugular venous distention, S3 (in HFrEF/volume overload), pulmonary congestion (crackles, dullness over pleural effusion), peripheral edema, hepatomegaly, and ascites. Sinus tachycardia is common. In pts with HFpEF, S4 is often present.
CXR may reveal cardiomegaly, pulmonary vascular redistribution, interstitial edema, pleural effusions. Left ventricular systolic and diastolic dysfunction are most readily evaluated by echocardiography with Doppler, and EF calculated or estimated. In addition, echo can identify underlying valvular, pericardial, or congenital heart disease, and regional wall motion abnormalities typical of CAD. Cardiac MR may be valuable in assessing ventricular structure, mass, volumes, and can help determine cause of HF (e.g., CAD, amyloid, hemochromatosis). Measurement of B-type natriuretic peptide (BNP) or N-terminal pro-BNP differentiates cardiac from pulmonary causes of dyspnea (elevated in the former).
CONDITIONS THAT MIMIC CHF
Pulmonary Disease: Chronic bronchitis, emphysema, and asthma (Chaps. 131 and 133); assess for sputum production and abnormalities on CXR and pulmonary function tests. Other Causes of Peripheral Edema: Obesity, varicose veins, and venous insufficiency do not cause jugular venous distention. Edema due to renal dysfunction is often accompanied by elevated serum creatinine and abnormal urinalysis (Chap. 38).
TREATMENT Heart Failure
Aimed at symptomatic relief, prevention of adverse cardiac remodeling, and prolonging survival. Overview of treatment of chronic HF is shown in Table 126-1; notably, ACE inhibitors and beta blockers are cornerstones of therapy in pts with HFrEF. Once symptoms develop:
Control excess fluid retention: (1) Dietary sodium restriction (eliminate salty foods, e.g., potato chips, canned soups, bacon, ...